Dealing with plantar faciitis: an update--Post Doctor Visit

After six weeks of not running and following several recommendations to the "T" and still no progress on regaining a pain-free left foot, I finally went to a medical specialist this morning for my nagging case of plantar faciitis-- a common running injury that is hard to treat successfully. The graphic to the left that I got from the AAOS web site shows it's location.

I've been suffering from a worsening case of plantar faciitis on my left foot and a secondary injury of hip bursitas on my right side (which since has subsided since I stopped running about 2 months ago) and intermittent lower-back pain (sacrum area), since December 2008.

The injuries seemed to correlate with a sudden-I'm-so-dumb-to-do-this jump in running miles (more than 10% increase each week) and writing a research paper on the foodways of triathletes and runners for an anthropology class. My days in December were sleep-deprived generally and usually involved long hours of sitting at my computer, sitting in my car on the 101 Freeway or in class followed by a long Saturday road run with the gazelle-like Inside Track Running Club ultra and marathon runners. ("Who needs to gradually increase their mileage to train for a marathon? Not me!") Nine months is long time for me to be nursing an injury. Lately, I've been doing more mileage writing and reading about running, than actually doing it. I've been a runner who can't run.

Since I forgot to ask the good doctor's permission to blab about his advice to me online, his identity won't be revealed. However, I'm confident he knows what he is talking about. He's an orthopedic surgeon who specializes in the foot and ankle, is athletic himself (runs and surfs) and has been treating foot injuries for twenty-five years. Finally, two of my doctor-swimmer friends recommended him.

After the doctor reviewed my gait and stance, an x-ray of my foot, and the wear pattern on my old NB 1224 running shoes, according to him, I had no obvious mechanical problems with my gait. Both feet have good flexibility and perform well. I just have a very painful heal (pain located at the mid-point/center and front area on the sole). And, I have tight soleus muscles. Apparently tight calves strain the plantar facia & Achilles tendons by deprecating my gait efficiency which puts additional weight and pressure on the arch/heal area with each step.

Here are his recommendations (as I understood them) to treat my plantar faciitis:

1. Wear a foam heal-lift in my shoes to remove the constant strain on my plantar facia & Achilles tendon's attachment on the calcaneous (heal bone)

2. Stretch my soleus muscle (muscle below the gastronemius that is just above the heal) with a wall stretching technique three times a day; Web pages that show how to do the stretches properly are at SportsInjuryClinic.net and at the AAOS web site.

3. Use ice on my heal/arch for pain management within 30 minutes after an activity inflames it; massage with ice is okay if done gently

4. Lay off strength training for a while: it's too soon for me to engage in heal lifts or heal dips or walking around barefoot if the heal hurts or hurts afterwards; As the doctor said, "If it hurts, don't do it!"

5. No running of any kind until the pain/inflammation subsides; That means no barefoot walking or running and no up hill, forefoot, or beach walking or running for a few weeks

6. Go for a walk on flat ground with supportive shoes (Brooks T5 with Superfeet insoles & foam heal lifts or NB 1225 with Superfeet insoles and foam heal lift) for a mile; then progress to a 1/2 mile walk, 1/2 mile jog (no faster than 8 or 9mpm for jogging intervals); and work up the mileage if there is no pain (If there is pain, back off and go back to walking)

7. When I can run again, practice a mid-foot running style with a shorter stride and feet landing underneath my center of gravity--not in front of me, landing lightly on my mid-foot before rolling off. For more information about improving one's efficiency through running mechanics check out RunningTimes.com for a mid-foot running article that covers the many current running biomechanic trends and philosophies such as Chi Running, Evolution Running, Dr. Ramanov's Pose Technique, barefoot running, etc. I got this from Clynton at Running Quest.net. He posts informative articles on running and diet with cited sources, too.

8. Continue using the night splint; stretch the calf muscles before getting out of bed each morning

9. Cross-train (continue swimming, weight training & riding my bike to keep up my cardio)

10. Gentle self-massage of heal and facia of arch on the foot every day followed by ice only if needed for pain and inflammation; As the doctor told me, "Ice doesn't help this injury."

Even though I wasn't running earlier this summer my heal pain kept hurting while I was doing my six-week Born to Run- and Advice-from-Friends- inspired "Everything But the Kitchen Sink" and two-week "Kitchen Sink" Plantar Faciitis Treatment Program. According to the doctor, I kept straining my arch/heal facia by strength training too early (calf raises and dips, lunges and walking barefoot around the house and beach). These failed treatment programs culminated with two desperate (but enjoyable) barefoot jogs on the beach. Severe pain was the result of the final beach runs. It was only nagging pain before.

If this new treatment plan doesn't help then the doctor will consider putting my injured foot in a cast for 4 weeks to take the pressure off my Achilles/heal or plantar facia. That means I can't do my dawn open water swims, though. And the thought of riding a stationary bike to keep up my cardio really isn't appealing. I hope it doesn't come to that.

My doctor didn't talk about the barefoot running nor of the forefoot running discourse in the running community. That may be because either he was unfamiliar with the trend of training this way with barefoot-in-the-grass running drills and strength training. Or, it may have been because he ran out of time for my appointment. He emphasized only that the calf muscles of one's leg drives and supports one's foot. This is a paradigm shift for me: my calves are a part of of my feet. To fix my feet I must first fix my calves by frequent (at least 2x/day) stretching of my soleus muscles done with correct form.

For now I'm wearing my $8 foam heal lifts from Ventura Orthopedic in my lightweight and flexible Brooks T5 running shoes, $70-ish (it was last year's model on sale), I bought at Inside Track with my $35 Superfeet insoles (green ones for high arches) that I also picked up at Inside Track. My left foot aches a bit today. But is probably from yesterday's painful one mile forefoot running experiment on the treadmill. And, playing with the kids in the water at the beach yesterday--barefoot of course.

Thank you so much to those who have left me informative comments & encouragement!

Dealing with plantar faciitis: an update

After six weeks of following my Everything-but-the-kitchen sink Plantar Faciitis Treatment Plan my foot still hurts.

This is a real bummer.

Briefly, my six week Everything-but-the-kitchen sink Plantar Faciitis Treatment Plan was:

• Ice pack treatment 2x/day (no longer than 10 minutes each per my doctor friend)
• Ibuprofen when there's arch/heel pain/inflammation (per my retired PT friend)
• Wearing shoes with arch supports such as SuperFeet all the time--even at the beach
• Calf strengthening exercises: positive heal rises 3 sets of 20 and negative (off a step) to exhaustion, for each leg every other day
• Stretching my calves, hamstrings, glutes--everyday
• Cross-training everyday by either swimming, road cycling, or 30 minutes on the elliptical machine with weight training of my upper body everyday
• Survive a pain and straight-talk session once a month with my gifted and no-nonsense Rolfer who keeps repeating "Don't run for two months!"
• Wearing a night splint (which keeps my arch stretched while sleeping), etc.
• Complain about it and my inability to do my favorite athlete past time ever: run

So, six weeks later, my heal wasn't hurting at all and I found myself with an hour to myself on Santa Cruz Island at the bottom of my very favorite running trail that meandered to the top of the bluffs. This beautiful trail gives a 360 degree view of the island's windswept hills, sea lion and seabird nesting areas on the rocks below, it's still native chapparel-covered peaks, and a soaring view of the mainland across the Santa Barbara Channel and open ocean with seagulls and pelicans flying by.

I jogged up the hill.

Thirty-five minutes later back at the bottom of the trail, my heal hurt. A lot. Damn.

The soreness went away a few days later so when I found myself at Moonlight Beach, site of my very first full triathlon (Bud Light Series, Olympic Distance, 1988) I thought that a barefoot run on the hard packed sand might be good for it.

I was wrong. After thirty minutes of trying to jog like a Kenyan or Tarahumara (landing on the forefoot, heals flicking up and faster turnover), my heal hurt. A lot. Again.

Damn.

Okay, so here's my new Kitchen Sink Plantar Faciitis Treatment Plan:

• See an orthopedic surgeon who specializes in feet, has been recommended by a former patient or medical doctor and who is athletic; the appointment is tomorrow and I'm anticipating it with both hope and fear (What if he can't do anything for me or recommends expensive options such as custom-made insoles that don't work?)
• Ice pack treatment 2x/day (longer than 10 minutes each per myself)
• Take two Advil when there's arch/heel pain/inflammation
• Wear my new Brooks T5 Racing Flats (last year's model to this year's "T6" that I got on sale) with the disco shoelaces with a pair of SuperFeet high arch (green) insoles when I'm not icing my feet, showering, swimming, riding my bike or dreaming.
• Do calf strengthening exercises every other day (positive heal rises 3 sets of 20 and negative (off a step) to exhaustion, for each leg)
• Stretch everyday (calves, hamstrings, quads, glutes, lowerback)
• Cross-train everyday (Swim, bike or do 30 minutes on the elliptical machine with some free weight training of my upper body)
• Wear a night splint (which keeps my arch stretched while sleeping)
• Avoid wearing flip-flops, shoes with no arch support or walking barefoot whenever possible
• Tweet about my Plantar Faciitis woes on Twitter in hopes that some one can offer me some good advice, encouragement or at the very least, commiserate (misery loves company)
  

Since I've been complaining about my running injury on Twitter, a lot of people have kindly shared advise or words of encouragement. So many people have tweeted me that I am really feeling good right now. My heal still hurts but everything feels great. Especially my heart.

Here's some of the Tweets I've received about treating Plantar Faciitis or offering encouragement:

"@Superfeet@multisportmama Hoping you get some relief – if we can be of any help, please let us know! 1.888.355.3338"

"@RaceSpeed@multisportmama Let me know what you find with your PF. Swimming seems to be good. Enjoy."

"@trijd@multisportmama Hope you get rid of it soon."

"How is the foot? Been able to do any BF running? Would love your thoughts on new post http://bit.ly/HPlxg" (Direct Message)

"@RaceSpeed@multisportmama Be careful with this type of injury. Here is a link to wikipedia write-up http://bit.ly/UnMD They say time is best cure."

"@RaceSpeed@multisportmama At bottom of this article is more links to exercises that help RT @faceurfears: Top 10 Sports Injuries - http://shar.es/qxtU"

"Thanks for the follow. Have you tried Active Release Therapy on your calves for your Plantar Faciitis? Worked instant wonders for my wife." (Direct Message)

"@kchealy@multisportmama you're welcome. I hope your PF resolves soon...it's a pesky injury!"

"@RaceSpeed@multisportmama Two points, bear with me. 1) If going on for 6 weeks without running, I worry and definitely worth Drs visit."

"@RaceSpeed@multisportmama 2nd point, I found video claims good for all foot related weakness injuries. http://bit.ly/15Srde Worth a look at."

"@kchealy@multisportmama the thing that helped me with PF was massage. Very painful but effective."

"@boulderrunner@multisportmama in my experience it [visit to a podiatrist] can be [a waste of money]. They love custom footbeds. Don't underestimate rolling on a golf ball and rest"

"@michaelsally@multisportmama well, depends on the dr. Most traditional drs like drugs or the cut & burn approach. Neither solve the cause."

"@runnrgrl@multisportmama pf sucks. Are you getting orthotics. After 3 mths of finetuning, mine helped! Still no more pf since-2 yrs of relief so far"

"@donna_de@multisportmama I'm reading Chi Running on the same topic [barefoot running]!"

"@ajrizza@multisportmama I see runners all time with PF we do foot and ankle exercises, EPAT (check out link) and Orthotics from Foot Management ..."

"@wildcelticrose@multisportmama the story of the accident-shows that an athlete can overcome anything http://wildcelticrose.net/l..."

"@the17thman@multisportmama @FootPursuita You should try Aqua Aerobics http://bit.ly/eldVE"

"@behindtherabbit@multisportmama thinking a lot about adopting 'less shoe is better' - slowly, to avoid injury. starting with light trainers, then mayB VFFs?"

"@dnorton@multisportmama I will go out on a limb to say a little barefoot running may actually help your PT. It has with mine... YMMV."

"@bmolloy@multisportmama I had PF last year for the first time and it took 3 months to be gone completely. heat moldable orthotics were my cure."

"@RunningQuest@multisportmama That's great! Remember to take it slow, to give yr muscles time to awaken. Good news is they do so pretty quickly."

"@healthyashley@multisportmama I'm sorry about the news (and pain!)... Good luck with your alternative exercises! Can you bike?"

"@turtlescanrun@multisportmama I guess you are with us on that list...It is so hard sometimes..I'm always injured or recovering lately :S"

"@ultrarunnergirl@multisportmama best advice 4 PF i know: keep supportive shoes on all the time, never go barefoot, esp getting up in a.m. or @ nite 2 pee."

"@DCrunnergrrl@multisportmama I know how you feel! Contemplating one of my 1st runs "back" tonite, and trying to make sure I don't jump the gun. So hard!"

"@ncjack@multisportmama awesome! How's the PF??"

"@misb@multisportmama how's the PF? Hope it's settling down! Orthotics, ART, & the night splint cured my chronic case."

"@misb@multisportmama it's Active Release Technique http://bit.ly/7xB4V & http://bit.ly/ZVzis ; really helps with soft tissue/fascia issues"

"@chicrunner@multisportmama gosh! get better soon. I am stretching as I type ha ha :)"

"@IronmanLongRunr@multisportmama I say tape it strong and give her a go"

Thank you everyone. Just knowing that there are people out there (fellow runners, parents, triathletes, non-athletes--people) who care enough to take a minute to Tweet me a word of encouragement or healing advice for my plantar faciitis really rocks.

It makes me feel better.

:) A

Dealing with Plantar Faciitis, review of article about barefoot running & less is more running shoes

"Barefoot Running: Not just for bums and hippies", is a well-researched blog article found at runningquest.net. It's an excellent source of news about the new discourse in the running community about the benefits of running barefoot or with "less is more" minimal running shoes.

The trend seems to be inspired by the book Born to Run by Christopher McDougal that came out earlier this year. The book documents the author's search for a cure for his nagging running injuries including the dreaded plantar faciitis (PF) that has ended running for many. The "Barefoot Running..." article's author Clynton expounds on the McDougal's findings about barefoot running, the running shoe industry marketing shoes known to be bad for running efficiency, and current articles. He also, very nicely and responsibly, cites his sources. (I love that!)

According to Clynton the benefits of running barefoot are these:
1. Shock absorption: Barefoot running makes you run using the body's natural shock absorption system by landing mid-foot while conventional running shoes force you to land on your heals which is damaging [my paraphrase]
2. Lighter Strike: Landing more lightly on your feet happens naturally barefoot [my paraphrase]
3. Muscle Strength: Your feet become stronger and more resilient to injury when running barefoot [my paraphrase]

What I also found useful were his several reviews of minimalist running shoes such as the Nike Free racing flats and Vibram Five Fingers shoes.

I used to run barefoot on the beach in my twenties as an undergrad at SDSU. I felt better, more free, and lighter running barefoot than plodding along on the concrete bike along the beach in my big running shoes. I had sore calves after my barefoot runs, but that was it.

Flash forward 20 years with 2 kids, 2 great careers (one in sales, other in web design) and current grad student & PT web designer ...

Bare with me on this, but I believe that our occupation, which effect the movements we do every day habitually, is directly connected to our fitness. My occupation, unfortunately, requires me to sit on my butt for hours--all day sometimes--and that is not conducive to being physically fit.

I'm not running now because of a nagging case of the dreaded plantar faciitis injury. The facia, a tendon that acts as a shock absorbing and flexible band runs from my heal to my forefoot, is badly strained and inflamed. (See drawing at the left of the Plantar Fascia from the American Academy of Orthopedic Surgeons helpful web site.) This is the the same injury that prompted author Christopher McDougal to write his book Born to Run.

To figure out how to recover from this cursed injury, my research included the above mentioned web site, several other web sites I found via Google, and two peer-reviewed articles written by physicians (that I found online via CSUN's library with my student access), and this very helpful little book that I found on Amazon.com: Injury Afoot: 30 things You Can Do to Relieve Heel Pain and Speed Healing of Plantar Faciitis by Patrick Hafner. It seems that my case of plantar faciitis comes from a combination of variables:

1. Weak feet. At the time of injury I was sitting all day and doing short "maintenance" jogs 3-4x week--no more than 45 minutes long each.
2. Wearing heavily structured and cushioned running shoes; In my case it was the NB 1223) during my sleep-deprived grad school semesters (sleep deprivation inhibits tissue repair, etc)
2. Tight calves from inadequate stretching (because I was always in a hurry to get my run in),
3. Weak abdominal muscles (probably from sitting hunched over a compooper all day (miss-spelling of "computer" is intentional!)
4. Walking around in stiff/arch-free flipflops all day (we live at the beach) which further caused my foot muscles to atrophy
5. A dramatic increase in my weekend long runs in a couple of weeks (from 5 miles to 14 miles--more than double) when I joined our local running club in November 2008.
6. Ignoring the nagging pain in my left foot PF for months, favoring my right foot which did two things: (1) made my injury worse and (2) gave me another injury: hip bursitis on my right side. This was probably caused by subtly shifting my weight off my left injured foot to my right foot. So, I came down with two injuries by December 2008 and by May 2009 I could not walk without extreme pain, on both sides of my body and suffered from lower back pain. How dumb is that? See where ignoring the obvious gets you? Don't do what I did!

So, unlike Clynton's article implies, my case of PF is due to more than atrophied foot muscles and tendons caused by over-structured expensive running shoes, it was my lifestyle too. However, I believe those shoes contributed my weaker arches in general and, eventually, plantar faciitis. But not by themselves.

I thought my years of racing and "muscle memory" could carry me through the jump in miles. I've done 20 marathons and used to train mostly on hilly trails. As an out of shape and older grad student, road runner and web developer, my "old school" attitude that training intelligently was for beginners, got a rude smack down by the reality of my current state of fitness. I had forgotten the miles and months it used to take me to get in good running shape when I was younger.

Right now I'm walking (not running) around in a new pair of NB 1224s with Superfeet insoles for high arches nearly all my waking hours. Even with dresses. Not very flattering but I figure it's my version of foot cast. It allows the plantar facia to heal and, unfortunately, atrophy. I'm no longer in pain with I walk but the tenderness is there and I have to be very careful and slow with my feet strengthening exercises and walking barefoot right now--or I'm back to square one.

(1) My Everything-but-the-kitchen sink Plantar Faciitis Treatment Plan:

• Ice pack treatment 2x/day (no longer than 10 minutes each per my doctor friend)
• Ibuprofen when there's arch/heel pain/inflammation (per my retired PT friend)
• Wearing shoes with archsupports such as SuperFeet all the time--even at the beach (this really was not fun at the Hurley US Open Surf Championship two weeks ago!)--per my graduate adviser at CSUN who suffered from PF
• Heal rises: positive 3 sets of 20 and negative (off a step) to exhaustion, every other day
• Stretching my calves, hamstrings, glutes--everything every day
• Cross-training once or twice (if I'm lucky) a day by swimming, cycling, core workouts, elliptical workout, or weight training
• Survive a pain and straight-talk session once a month with my gifted and no-nonsense Rolfer who keeps repeating "Don't run for two months!" (I just repeat his words over and over again when I'm tempted to skip..errr... I really mean run... down the beach a bit after an open water swim or when I'm with the kids).
• Wearing a night splint (which keeps my arch stretched while sleeping), etc.

If you suffer from Plantar Faciitis, the book Injury Afoot: 30 things You Can Do to Relieve Heel Pain and Speed Healing of Plantar Faciitis may help you with it's plan to get rid of it. So far, when I follow that little book's steps for healing and strengthening exercises, my foot is pain-free.

(2) As soon as my PF is healed, the plan is for me to return to barefoot running on the beach to strengthen my feet. Gradually--just mile or two at first. I've come to realize, during this injury, that my body needs more than muscle memory to get conditioned, especially at my age.

That being said, my footwear plan:

(1) I will get a pair of Vibram FFs. They fit my feet fine and the weird factor is kinda cool in my book. I like them. They crack me up! Also, I think Barefoot Ted (from book Born to Run) is on to something.

(2) For road running I also have a pair of Brooks Cascadia 4 trail running shoes that I got just before my PF injury got too painful to run. I like them, too, and I feel that my foot can flex more naturally while wearing them. I heard that Scott Jurek designed them. Maybe he added some magical running powers to their design. I need it.

(3) I don't think I will go back to wearing conventional running shoes. But, then when marathon training on concrete and asfault I'm not sure if the Vibrams and trail running shoes will adequately protect my feet from injury. I'm waiting to hear more and may purchase a pair of racing flats for this reason in the future. I was considering the Nike Free or a NB racing flat (if they have one) but I'm kinda pissed off at Nike and coventional running shoe companies right now for inventing and marketing the over-structured/padded running shoes that contributed to my running injury in the first place. I still don't know what to get.

Please comment and keep me updated on your own barefoot running or "less is more" running experiences! And, feel free to offer any "less is more" running shoe tips.

:)